Teaching Theories and an Ethical

Teaching Theories and an Ethical Nursing Situation

The purpose of this paper is to apply a learning theory to an actual educational case study and scenario. The situation must be seen from the point-of-view of the nursing student scenario. The situation must be challenging to handle. This includes being able to identify events and critical indicators of the scenario that made the case challenging to the student. These indicators may include: a student's developmental state, education level, socioeconomic standing, cultural status or any personal, family factors that may influence the situation.

Literature suggests that these indicators apply in situations of an ethical nature and the challenge remains to make the right moral decision. Nurses are faced with moral and ethical issues every day especially when it comes to building a relationship of trust with the patient. Research also suggests that the indicators above influence one's ability to make the correct choices as different views on truth telling within the medical community exist. Still due to the prevalence of "lawsuit happy" society, slowly an ethical framework and protocol is being adopted world wide when it comes to ethical issues like truth telling. Ethics can be challenging for a nurse when faced with coworkers and other associates who may have a different set of values and the nerve to deviate from protocol and hospital policy. The issue meant to be explored from the student's point-of-view is the influence of family on patient care and the patient's right know their condition and course of treatment for that condition. The scenario will be described in greater detail in paragraphs below. This paper is also meant to explore the events and indictors that the student may be influenced by if such a scenario should present itself in their career. How will they react? Has their training given them the framework from which to treat the patient while dealing with a family's influence on treatment. This paper will also present a theory and model from which one can guide the process of intervention. Within in this theory, one can examine applicable issues involved with the scenario and offer the student feedback. For the purpose of teaching nursing skills, it is important to look at the framework in which the profession is built and look at evidence-based nursing as a framework. This will allow one to explore theories presented by Bigge and Shermis that behavior influences outcomes. This allows the paper to take the scenario one step further to describe how a more experienced nursing student would intervene in the scenario. This will require further analysis of existing theoretical tenets and the critical indicators that may affect this student's intervention plan.

Case Study: A Nurse's Dilemma, Challenging Scenario

From the case study proposed by Joan Callahan (1988), imagine now that you are a nurse on a medical/surgical floor in a large private hospital (p. 4). A woman is admitted on a Sunday for a series of medical tests you are assigned as her primary nurse. The testing begins on Monday and you are off for the next few days. You return to work the following Saturday and resume your duties as the woman's primary nurse. When you arrive on the floor, you go over her chart and find that the tests have revealed that she has chronic lymphocytic leukemia and is being transfused in an attempt to put the disease into remission. As you approach her that morning she greets you happily and asks you if you know when she will be able to return to work given her diagnosis you are a bit puzzled by her exuberance and you judiciously reply that you have not seen her physician since her return to work but that you will talk with the physician about her d/c from the hospital

On your way back to the nurses' station, one of the woman's two daughters approaches you and urges you to assure her mother that there is no reason for concern. Her daughter tells you her mother has just been through a painful divorce and that she and her sister had decided her mother should not be burdened wit the news that she has a terminal illness. You discuss the whole situation with your head nurse. She tells you to talk with the woman's physician who is also the new director of the hospital's medical service. You avoid going to the woman's room until the physician arrives on the floor. When she arrives you tell her about the woman's request for information regarding her discharge and about your conversation with the daughter. The physician informs you that the woman has been told simply that she has refractory anemia (which in fact is a result of leukemia) and has not been told the true nature of her illness in order to spare her unnecessary anxiety. You protest that the woman does not seem mentally unsound in any way and therefore she has a right to know about her diagnosis and prognosis. Still the doctor interrupts you and says that further disclosure on your part would have to be considered inconsistent with the best medical care of this woman. You are deeply troubled and return to your head nurse who is sympathetic but advises you to follow the physician's suggestions.

Events and Indications of a Challenging Scenario for Student Nurses

The above scenario creates a challenging situation with a myriad of solutions. One point of action is to employee strict ethics in truth telling while performing tasks to gather further information to aid in treatment. One can base a course of treatment off the evidence obtained, however it is clear with any framework or theory from which to act events and indicators will become an issue for each individual. There are many thoughts on how a person learns and processes information. Many schools of thought believe that it does not matter the level of education but hands-on, on-the-job training is the only experience that makes the student thrive. Bigge and Shermis (1999) would argue that this theory makes too many assumptions about behavior that "human beings are passive or reactive and cognitive interactionists make the assumption that human beings are interactive" (Allen, 2005, p. 254). Instead some humans learn through a process of impression of new reaction patterns and the environment around them.

From this perspective with respect to the above scenario, it is important that all factors for the individual be realized and carefully considered. As a new nurse, they may lack experience on hospital protocol and policy or they may be sticking strictly to the book. The issue here is, can ethics be learned by the nursing the student in order to aid in situations described above? Is it just a matter of following the rules? Research suggests that one's definition of ethics and behavior during ethical situations can be based on cultural, socioeconomic and familial factors. Dr. Braddock (1998) writes, "one must create sensitive dialogue when conveying bad news as religious beliefs or ethic and cultural may have different views on the appropriateness of truthful disclosure" (p. 3). This applies also to staff who is conducting the truth telling. One should not make any assumptions about any party but provide them with the expected respect provided during care. In the situation above, it appears the patient is not depressed or unable to make decisions for herself. It is important for the student to gather evidence otherwise and work for this perspective depending on comfort level. Medically, there have been situations where telling the truth will cause more harm than good but this is not the situation. Dr. Braddock (1998) concludes, "being honest is an important way to foster trust and show respect for the patient" (p. 1) and in this scenario the physician is failing the patient ethically. Not only must a nurse be to gather information on their own perceptions taking into account their own background but they must be impartial to the background of the patient and immediate family. Unfair assumptions about the present patient that she is depressed, lacking high self-esteem, worried about finances and building a new life is not reflected in her present behavior maybe because she is not aware of how truly sick she is really. An inexperienced nurse/student may have a tendency not to question the doctor or patient's family but it is important to gather new information and continue objectivity keeping hospital policy in mind. This may mean telling the patient the truth.

How the nurse functions and interacts with the patient is also impacted by evidence-based practices. The signs and symptoms have a second meaning: how people deal with them in their daily life in order to participate in medical diagnosis and treatment in an intelligent manner (Evers, 2001, p. 3). Self-care problems or family care issues in assessment, management or follow-up of pain and other ailments. Inadequate self or family care is impacted by evidence-based practices and helps to assess and communicate experience in the treatment. Still there can be difficulty in assessing pain and disability due to misconceptions and can lead to patient addiction, cognitive impairment and side effects. Unfortunately, most quantitative studies lack external validity in the research design to allow for general conclusions.

Teaching Theories and Nursing

It was Nightingale that recognized the potential of combining sound logical reflection and empirical research in the development of scientific knowledge that lead to evidence-based practices of today. She saw the need to only classify one's illness by the best possible available knowledge but to also collect patient information in the form of survey. Nightingale's work was also groundbreaking as it was the first to integrate such ideas into one method. She understood how factors such as housing and nutrition could have a direct influence on the patient's health and prognosis (McDonald, 2001, p. 68). Still many researchers to come would look at her work as primitive, inconclusive and one-sided. They would see how such details act as an extension of evidence and the attention paid to details as research of evidence (McDonald, 2001, p. 68). Many academics would argue that Nightingale served her purpose to offer a foundation for modern nursing but did not invent evidence-based nursing. Is it possible that such a foundation could grow into something broader to encompass modern research?

Many researchers argue the credit Florence Nightingale is given as the founder of modern nursing, evidence-based nursing and care. Many researchers argue that the framework in which evidence-based care is principled on did not exist prior to the 1960s and that the Nightingale method of questioning and survey also died with the matron. Simply, this is the basis of any academic dilemma, which side is right and which side is wrong? Literature suggests many points-of-view when it comes to evidence-based nursing and its evolution into a primary method of treatment in modern medicine. It is method not only used by nurses but also doctors and other medical professionals. Part of the issue and what raises evidence-based nursing and care as debated issue is the fact that it can be difficult to effectively label evidence. Depending on the professional consulted, each may have a different insight into what defines evidence and how it is collected. George Castledine believes evidence-based nursing did not start until the 1960s. Castledine (1997) writes, "research or evidence can be used in more than one way and the sue of research as a specific form of knowledge involved political, organizational, socioeconomic and attitudinal components" (p. 1).

This only opens the issue to more analysis as one contemplates the factors that make up evidence-based nursing. Is it fair for evidence to be based on guesswork? He also cites, "the problem with evidence-based approach is that it may become obsessed with the academic basis of nursing and fail to acknowledge the art of the subject" (p. 1). This creates the concept that nurses need to not only implement a fact-finding approach not just based on medical knowledge but also on humanity. Castledine (1997) believes, in order for such a method to work there must be a healthy balance (p. 1). Still this argument is just one point-of-view and does not create a framework or description of modern nursing. It, however, is advise to the nursing student in how to formulate their own approach. David Sackett, et al. (1996) understand the historical basis of such a method but are concerned with the power it presents to nurses. There is the concern that the practice while innovative may be out dated and only used to cut administrative costs to the health care system. Sackett, et al. (1996) write:

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systemic research. (p. 71)

While clear and distinct, this definition seems conservative in nature and devoid of creative, critical thinking. There is also the concern in modern medicine that when faced with a scenario of treating a patient, two outcomes will result. One, nurses will rely too heavily on their gut instinct and passion for care or two, nurses will look to clinical explanations and medical knowledge more than actual symptoms and listening to the patient's needs. This leads to problems regarding quality of care, customer service and administrative cost benefits. In this day and age of managed health care, evidence may not play a greater role; the reality of treatment efficiently becomes the main issue for hospitals. This can lead to mistakes, lack of compassion and possibly liability. With this in mind not only is it important for nurses to use all skills available it is also important to examine the impact that evidence-based medicine has on nursing practices and the welfare of the profession.

Possible Interventions

Once the nursing student has observed the situation and gathered evidence to support his or her continuing treatment, it is important that they must follow hospital policy of a patient's bill of rights. Dr. Drane (2002) writes, "the loss of reputation for honesty in medical practice means the end of medicine as a profession" (p. 1). Clearly there is great concern for current behaviors to deviate from ethical codes of conduct and how such behaviors are influenced by outside agents. As a part of invention, one must also take into account how a person's behavior predicts future behavior. As voiced earlier, this may stem from a cultural background where it is seen that not telling the truth is acceptable behavior. Leaving a situation without taking action or voicing any information can have the same impact and cause harm but may still be seen as acceptable by that person (Drane, 2002, p. 2). As a nurse, it is part of the job responsibilities to convey the correct information to the patient about their diagnosis and treatment. This continues to challenge the nursing student and educators as they search for new ways to intervene.